From the Guidelines
Lumbar stenosis should be initially managed with conservative treatments, including physical therapy and over-the-counter pain medications, with surgical options considered only if conservative treatments fail after 6-12 months or if neurological symptoms worsen, as recommended by the American College of Physicians and the American Pain Society 1.
Initial Treatment
Initial treatment for lumbar stenosis typically includes:
- Physical therapy focusing on core strengthening and flexibility exercises
- Over-the-counter pain medications like acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) or NSAIDs such as ibuprofen (400-800mg three times daily with food) for pain relief
Medications for Severe Pain
For more severe pain, prescription medications like gabapentin (starting at 300mg daily and gradually increasing) may help with nerve pain, as suggested by the American College of Physicians and the American Pain Society 1.
Lifestyle Modifications
Lifestyle modifications are crucial, including:
- Maintaining proper posture
- Using supportive chairs
- Avoiding heavy lifting
- Weight management to reduce pressure on the spine
Surgical Options
If conservative treatments fail after 6-12 months or if neurological symptoms worsen, surgical options like decompression laminectomy may be necessary, as recommended by the American College of Physicians and the American Pain Society 1. Surgery aims to create more space for the nerves by removing portions of bone or tissue causing compression.
Diagnostic Imaging
Diagnostic imaging, such as magnetic resonance imaging (MRI) or computed tomography (CT), should be performed only if patients are potential candidates for surgery or epidural steroid injection, as recommended by the American College of Physicians and the American Pain Society 1.
From the Research
Definition and Prevalence of Lumbar Stenosis
- Lumbar spinal stenosis is a prevalent and disabling cause of low back and leg pain in older persons, affecting an estimated 103 million persons worldwide 2.
- The prevalence of the clinical syndrome of lumbar spinal stenosis in US adults is approximately 11% and increases with age 2.
- Lumbar spinal stenosis affects more than 200,000 adults in the United States, resulting in substantial pain and disability 3, 4.
Symptoms and Diagnosis
- The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency 3, 4.
- The pain is typically burning or cramping, which worsens with standing and walking and improves with bending forward or sitting 4.
- Magnetic resonance imaging is the recommended diagnostic test because it allows cross-sectional measurement of the spinal canal 4.
- The diagnosis can generally be made based on a clinical history of back and lower extremity pain that is provoked by lumbar extension, relieved by lumbar flexion, and confirmed with cross-sectional imaging, such as computed tomography or magnetic resonance imaging (MRI) 2.
Treatment Options
- Nonoperative treatment includes activity modification, oral medications to diminish pain, and physical therapy 2.
- Surgery appears effective in carefully selected patients with back, buttock, and lower extremity pain who do not improve with conservative management 2.
- Decompressive laminectomy improved symptoms more than nonoperative therapy in a randomized trial of 94 participants with symptomatic and radiographic degenerative lumbar spinal stenosis 2.
- Lumbar fusion increased symptom resolution in patients with lumbar spinal stenosis and concomitant spondylolisthesis, but is associated with greater risk of complications 2.
- Multimodal care nonpharmacological therapies, including education, advice, and lifestyle changes, behavioral change techniques, home exercise, manual therapy, and/or rehabilitation, are recommended for patients with lumbar spinal stenosis causing neurogenic claudication 5.
- Serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants may be considered for patients with lumbar spinal stenosis causing neurogenic claudication 5.
- Epidural steroid injections are not recommended for patients with lumbar spinal stenosis causing neurogenic claudication due to lack of long-term benefits 2, 5.